1. Neonatal and Perinatal ExtraAxial and Extracranial Hemorrhage Shirley Chan 1 Natalia Marks 1 Keith Cauley 1 Columbia University Medical Center- NY Presbyterian Hospital Control #: 2841 eEdE#: eEdE-200

2. Disclosures The authors do not have affiliations with a commercial organization that may have indirect or direct interest in the content.

3. Purpose This presentation is aimed towards radiologists and radiologists-in-training and is a review of extracranial and extraaxial hemorrhage in the neonatal to perinatal population: Learning objectives include: Review of relevant anatomy Understand key imaging findings Discuss clinical prognosis, differential diagnosis, and possible complications if applicable

4. Approach Case based format Topics include: Vaginal birth, vacuum assisted delivery, trauma, infection, coagulopathy

5. Types of Hemorrhage Extracranial/scalp Caput Succedaneum Cephalohematoma Subgaleal hematoma Extra-axial Epidural Subdural Subarachnoid

6. Layers of the SCALP- Mnemonic From superficial to deep: S: Skin contains hair follicles and sebaceous glands (lacerations and abrasions; typically better seen on physical exam) C: Connective tissue; mostly subcutaneous fat A: Galea or epicranial aponeurosis; dense fibrous tissue which runs from the frontalis to occipitalis muscles L: Loose connective tissue P: Periosteum

7. Case 1 1 day old neonate male presents with prolonged vaginal delivery

8. Case 1 Findings Cone shaped head with prominence of the vertex soft tissues consistent with head molding Findings can be seen with caput succedaneum

9. Caput Succedaneum Subcutaneous serosanguinous fluid collection Associated with head molding Occurs in labor stage 1: Formed by pressure on the fetal calvarium against the dilating and shortening cervix Crosses midline and suture lines Resolves over the first few days No complications* Patients are not images typically * McQuivey RW. Vacuum-assisted delivery: a review. The Journal of Maternal-Fetal and Neonatal Medicine, 2004; 16: 171-179

10. Case 2 13 day old full term neonate with vacuum assisted delivery presents with possible seizures. What are the findings? Localize the lesions.

11. Case 2 Findings Axial STIR and sagittal T1 MRI head images show bilateral parietal scalp collections containing fluid-fluid levels (hematocrit effect). The hematomas cross suture lines and are located deep to the subcutaneous fat, localizing them subgaleal.

12. Before and After 3 months later, the subgaleal hematomas have completely resolved. The left sided images are the earlier images and the right sided images are the more recent images. Hematocrit effect may suggest underyling coagulopathy, but the hematomas resolved.

13. Subgaleal Hematoma Discussion Hemorrhage in the potential space between the galeal aponeurosis and periosteum. Seen in vacuum assisted delivery or head trauma Increased morbidity compared to other scalp hematomas; can lead to hypovolemia and coagulopathy* Prognosis generally good with treatment* Radiographic Features: Crosses suture lines Commonly seen with other injuries if head trauma (intracranial hemorrhage or skull fracture) *Chadwick L, Pemberton P, Kurinczuk J. Neonatal subgaleal hematoma: associated risk factors, complications and outcome. Journal of Paediatrics & Child Health. 1996;32(3):228-32

14. Case 3 3.5 month old full term male with vacuum assisted delivery

15. Case 3 3.5 month old full term male with vacuum assisted delivery

16. Case 3 Findings Coronal, saggital and 3D reconstruction CT images show a partially calcified or ossified lesion in the left parietal calvarium.

17. Case 3 Findings T1 (upper left), T1 post contrast (lower left) and T2 coronal (lower right) images demonstrates a left parietal scalp lesion located deep to the subcutaneous fat and closely associated with the inner table. There is central enhancement.

18. Cephalohematoma Discussion Subperiosteal hematoma Usually caused by birth trauma Increased incidence with vacuum and forceps delivery 1,2 Generally good prognosis 2 Radiographic Features: Unilateral or bilateral Subgaleal collections that do not cross suture lines May calcify over time 1. Aberg K, Norman M, Ekéus C. Preterm birth by vacuum extraction and neonatal outcome: a population- based cohort study. BMC Pregnancy Childbirth. 2014; 14:42 2. O’Mahony F, Hofmeyr GJ, Menon V. Choice of instruments for assisted vaginal delivery. Cochrane Database of Systematic Reviews. 2010; (11):CD005455.

19. Case 4 4 month female patient post evacuation of hematoma after head trauma.

20. Case 4 Findings Axial CT images in brain parenchyma (left) and bone (right) windows show right frontoparietal extraaxial collection containing air, fluid and hemorrhage likely a post surgical collection. Right parietal nondisplaced skull fracture (arrow) is noted.

21. Epidural Hematoma Discussion Between the calvarium inner table and the periosteum/parietal layer of the dura Arises from meningeal artery tear or less likely venous sinus tear Not commonly seen in birth trauma* Radiographic Features: Bound by suture lines Lentiform shape Commonly associated with skull fractures Can cross midline *Odita JC, Hebi S. CT and MRI characteristics of intracranial hemorrhage complicating breech and vacuum delivery. Pediatr Radiol.1996; 26(11):782-5.

22. Case 5 : 11 week old male with Kleinfelter syndrome and alpha antitrypsin 1 deficiency presents with coagulopathy

23. Case 5 : 11 week old male with Kleinfelter syndrome and alpha antitrypsin 1 deficiency presents with coagulopathy

24. Case 5 Findings : Axial images from superior to inferior (upper row) and coronal (lower) CT head images demonstrates right frontal hyperdensity and layering hyperdensity in the posterior falx and right tentorium. Findings are consistent with subdural hematomas. Scattered periventricular frontal and parietal calcifications are suggestive of an infectious etiology such as TORCH.

25. Case 5 Findings : Sagittal T1 (upper left), coronal (upper middle) and axial T2 (upper right) and axial SWI (lower row) MRI images show right frontal subdural hematoma with hematocrit effect (blue arrow) and subdural hematoma layering along the right tentorium and posterior falx.

26. Subdural Hematoma Discussion Between the visceral layer of the dura and arachnoid membrane Due to tears in bridging vein, falx, or tentorium 1 Sometimes seen as isolated sequelae of vaginal birth trauma, commonly located in posterior fossa 1 Increased incidence with vacuum or forceps delivery 2 Radiographic Features: Crescent shape Crosses suture lines Does not cross midline (limited by dural reflections) 1.Looney, et al. Intracranial hemorrhage in asymptomatic neonates: Prevalence on MR Images and relationship to obstetric and neonatal risk factors. AJR 2007; 242 (2): 535-541 2.Castillo M, Fordham LA. MR of neurologically symptomatic newborns after vacuum extraction delivery. AJNR 1995;16:816 – 818

27. Case 6 32 week old male fetus with intracranial hemorrhage seen on screening ultraound.

28. Case 6 32 week old male fetus with intracranial hemorrhage seen on screening ultraound

29. Case 6 Findings : Fetal T2 weighted MRI images with fetal head in axial and sagittal planes demonstrates a moderate right holohemispheric and small left parieto-occipital subdural hematomas. Mass effect includes effacement of adjacent cerebral sulci and right to left midline shift

30. Subdural hematomas in a fetus is suspicious for non-accidental trauma or underlying coagulopathy Must prompt clinicians to avoid birth trauma during delivery Neonate was born via cesarean section Found to have hemophilia Subdural Hematoma Discussion

31. Case 7 1 day old full term neonate requiring vacuum assisted delivery and ventilation at delivery

32. Axial susceptibility weighted MRI images (SWI) show blood products layering along the tentorium, occipital horns (arrows) and bifrontal subarachnoid space. Case 7

33. Case 7 Findings No osseous abnormality on AP radiograph of the calvarium. Hyperintense T2 signal lesion superficial to the outer table appears to be confined to the suture lines. Findings are suggestive of a small cephalohematoma in the posterior frontal scalp.

34. Subarachnoid Hemorrhage Discussion Between the arachnoid membrane and the pia mater May be due to a bleeding vascular malformation, aneurysm, or trauma Least frequent intracranial hemorrhage seen with vaginal delivery or vacuum assisted delivery 1,2 Patient is being worked up for coagulopathy Radiographic Features: Fills subarachnoid cisterns and sulci Crosses sutures and midline Ventricular system contiguous with subarachnoid space 1.Looney, et al. Intracranial hemorrhage in asymptomatic neonates: Prevalence on MR Images and relationship to obstetric and neonatal risk factors. AJR 2007; 242 (2): 535-541 2.Odita JC, Hebi S. CT and MRI characteristics of intracranial hemorrhage complicating breech and vacuum delivery. Pediatr Radiol.1996; 26(11):782-5.

35. Case 8 3 month old female with hypoplastic left heart presents with acute hemiparesis

36. Case 8 MRI was obtained a week later

37. Case 8 Findings: Coronal ultrasound and CT images through the head demonstrate multifocal bilateral periventricular frontal and parietal echogencity and hyperdensity. Findings represent hemorrhagic conversion of bilateral frontal and parietal watershed infarctions.

38. Case 8 Findings Axial SWI (upper) and DWI/ADC (lower) images show: Intraventricular blood products layering in the left occipital horn Subdural hematoma layering along the posterior falx (arrow) Multifocal bilateral frontal, parietal and basal ganglia intraparenchymal hemorrhages. Areas of restricted diffusion in the right frontal blood can represent acute infarction or artifact from blood products.

39. Case 8 Discussion Clinical history of hypoplastic left heart with hemiparesis suggests an acute ischemic event caused by cardiogenic shock Bilaterality of findings in the frontoparietal regions and basal ganglia suggests hypoperfusion and hypoxemia Embolic infarction is a good differential and may also be contributory

40. Case 9 16 day old female with HSV and Klebsiella meninigits. Patient was born at 36 weeks gestation via Cesarean section for arrest of Stage 1 Labor. No history of vacuum or forceps assistance.

41. Case 9 Findings: Coronal T2 (left) sagittal T2 (middle) and T1 (right) MRI images demonstrates high parietal, left greater than right, hematomas that are located deep to the subcutaneous fat and crosses the midline, sagittal sutures. Findings are most consistent with subgaleal hematomas.

42. Case 9 Findings: Axial T2 (left) and SWI MRI images superiorly (middle) and through the posterior fossa (right) demonstrates a cystic lesion with a hematocrit level in the right frontal region and multifocal blood products near the tentorium and cerebellar hemispheres. Discussion: Multifocal bilateral cerebellar hemorrhages extending to the tentorium cerebelli likely represents septic emboli. Right frontal hemorrhagic cyst is also likely related to septic emboli or evolution of embolic infarction.

43. Summary/Conclusion Scalp hematomas generally have good prognosis Intracranial hemorrhage could have variable and potentially worse prognosis* Imaging finding of hemorrhage should prompt careful evaluation for additional sites of hemorrhage Hematocrit effect and degree of hemorrhage disproportional to the mechanism of injury can be due to an underlying coagulopathy or non-accidental trauma * Looney, et al. Intracranial hemorrhage in asymptomatic neonates: Prevalence on MR Images and relationship to obstetric and neonatal risk factors. AJR 2007; 242 (2): 535-541

44. Contact Information For questions or concerns, please contract the primary author at shc9117@nyp.org